Mosaic verrucae-help with treatment

Both - determined by location of VP

 

Ditto

 

Hi all,

I have followed this thread with interest since it first started. Recently I had a pt present with a large mother wart on the plantar aspect of the right hallux with a small lesion proximal and another VP appeared between the 3rd and 4th met heads between seeing her the first time and rebooking her for the multple puncture technique. She has previously had a verruca removed (on the same foot) a few years previous by a plastic surgeon as nothing she had tried could get rid of it. She is currently in her second trimester of pregnancy and was adamant she wanted the verruca gone before the baby comes.

I performed the multiple puncture technique on the mother wart only two weeks ago tomorrow. She came back for review today and after debriding the mother lesion it has essentially disappeared with healthy pink skin beneath. Her two other VP have got much shallower also. Needless to say she is thrilled with the results thus far.

I just wanted to say a big thank you to Kevin for making me aware of this technique!

 

Good to hear of your treatment success. Great job!

I have also found the technique extremely gratifying both for me and for my patients. By the way, from what I understand, there may be a group of members from Podiatry Arena who are planning on publishing a paper on the needling technique. This certainly seems appropriate since the last paper on the technique was published over 42 years ago, at a time before most of the members of Podiatry Arena were born! (Falknor GW: Needling-a new technique in verruca therapy: a case report. JAPA, 59:51-52, 1969).

 

Like everyone else in this thread I am keen to try this multi puncture technique on the next case of mosaic or multiple VPs that walk through the door. In the mean time I too have had great success using Thuja to treat VPs. One teenage boy who had VPs right across his right plantar metatarsal area tried all the normal methods over a period of years. He then used oral Thuja tablets and topical thuja liquid simultaneously for 2 weeks and all the Vps disappeared without a trace in this time. I have since used this treatment on girls with Icthyosis and multiple hand and foot warts, with similar success within weeks. It is important that patients using this treatment use it at regular intervals through the day and not sporadically. I have not tried it on any adults yet.
Also did anyone else see the episode of Embarrassing Bodies with the young girl with an extreme case of warts? Blood tests found this girl had no T lymphocytes, and maybe low white blood cells and a much more serious condition affecting her immune system.

 

This is a great discussion, i have only graduated as of dec 2010 and have seen one patient with this, after reading this information i now feel i can deal with patients who have severe cases of verrucae pedis. Esp Kevin information i wish we learnt this technique at uni.

Cheers
Phill

 

Not enough evidence.......yet

Still very much a work in progress, Kevin. However, we`ll get there :drinks


Cheers,
Bel

 

Hi all,
Thanks for a fantastic, informative and interesting thread. I have a patient (young girl) who has a stubborn mosaic verruca which has not responded to any treatments in 6 years. I feel she would benefit from verruca needling, but having not performed this before, would not feel comfortable doing it myself.
Is there anyone in Adelaide, South Australia practising this technique?? I would be keen to refer her to someone local to have the treatment.
I would like to start using this myself, but would prefer to learn from someone first!
Cheers for your replies!

 

and there is this clinical trial re triggering cell mediated immunity of multiple VP´s found here.

http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=155551&postcount=12

 

Hi there fellow pods.
I have seen numerous referrals back to this article: Parton AM, Somerville RG. The treatment of plantar verrucae by triggering cell-mediated immunity Brit J Pod Med 1994; 49:205.

But I can't for the life of me find a copy anywhere! There are many articles citing it but no copy can be found.
Could someone please post a copy of it on the forum.
Cheers

 

I have only treated one client for mosaic verrucae so far but it was very successful, they disappeared anyway, I used a caustic pencil in the centre of the largest cluster, after two weeks they had all but gone and have not returned as yet! As I am only a FHP I am unable to use the other techniques mentioned but am very interested to read and learn about them.

 

Hello All,

I'm another one of many that have been following this thread with great interest.
I'll plan to perform my first "needling" next week.

This gentleman is a 41 year old male who is in good general health. He has multiple verrucae on the plantar aspect of both feet. He noted that he had a similar presentation approximately 3 years prior but said that it had resolved after 9 months of routine and painful cryotherapy (every 2 to 3 weeks).

His current lesions have been around for approximately 1 year, during which he has not sought treatment. I've attached pictures of his right foot as there currently is only one VP presenting on the left.

He doesn't recall which lesion came on first - but obviously his R/lateral/plantar heel is more "involved". So I would think it would be the best lesion to needle - though is sub PMPJ VP may be easier to anesthetize (I would like to do local infiltration).

If I do needle the plantar heel VPs - there are many clusters with a number of satellite lesions - Would the technique be less effective if I only puncture the central portion? I would think it would still work to generate an immune response?
Or should I choose to needle the sub PMPJ VP because it's a circumscribed lesion?

Thanks for your help!

 

With any mosaic VP or one which appears not to respond to treatment I think it is important to establish if the patient has any underlyig problems with immune system, diagnosed or undaignosed.

I know of a young girl who presented with multiple VPs to the plantar feet and fingers, on questioning she had some symptoms which initiated bllod tests and revealed leukemia.
Needless to say once the leukemia was addressed the VP cleared. But also consider diabetes, steroids, perfusion to the area....and is it actually a VP you are treating??

 

AKYC:

If I was going to needle one area on this patient, from what I can see in this photo, I would choose the one I have marked on the photo. I would infiltrate from the lateral heel with 2 cc 0.5% marcaine plain, and use a 25 gauge needle to puncture the verrucae about 100-150 times at a 7 mm depth with each puncture until it was beefy red. Put a 4 x 4 sterile sponge on it with a 2" coban wrap to hold the dressing in place and have them start bathing normally that evening (2-3 hours post op). Bandaid the area for two days following the procedure.

Please take photos at every post-op visit for the rest of Podiatry Arena. Your photographic technique is excellent. Good luck.

 

Thank you for your advice Kevin - greatly appreciate it. I'll do just that.

When you suggest to inject at the lateral heel - am I correct in assuming that I should inject more superiorly (i.e., not on a plantar weight bearing area) as the skin in that area is not as thick (and perhaps painful - though I do plan on using Pain Ease spray) and since I can easily reach the area you've marked with 1.5" needle?

I also currently only have lidocaine at my clinic - which I'm sure is fine as well...?even though it has a shower duration.

 

In this area of the foot, I would inject at the lateral heel to avoid injecting into the plantar aspect of the foot since this should be a much less painful area to inject and should have much thinner skin.

 

Hi Kirby, could you please post the article you often referred to: Parton and Sommerville. for all to see please.
Many thanks.

 

Hello again all,

I performed the needling procedure on the patient I had presented on the thread last week (See pictures above).

Kevin - Thanks again for your help. I needled the exact area you suggested. The local infiltration injection was a little trickier than I had anticipated - but it worked out in the end. On a pain scale, the patient rated the pain from the lateral heel injection a 4 out of 10 (ethyl chloride spray was used).

I've posted a post needling picture. Please note that the right lateral heel is the most involved area - and the patient is prone in this picture. Please see above for the "before" picture in which Dr.Kirby outlined the suggested area for needling.

Will be back in 2 weeks to post a follow up picture! Here's hoping my first attempt will be a successful one!!!

 

Does anyone have any advice how to treat verrucae without the use of LA?

The above posts are very interesting, but I don't do local anaesthesia. I opened a chiropody surgery a few months ago after 11 years of domiciliary practice and about a third of enquiries are for verrucae. Help!

 

Why not do a LA course ?

 

Well, erm, can I admit this here, I have a phobia about needles. Always have since I had a very painful injection as a five year old child. My mum tried to help me by getting me to inject her insulin, but it just made it worse.

 

No shame in that. In fact, I had the very same. I knew I had to get over it in order to complete the degree. So, I convinced myself that the sensation of an injection was the converse to painful.....the rest is history.

Mr Isaacs has a theory on that. Not so sure myself.

 

you're just kinky

 

Thanks Steve

Seriously, it was you who helped me overcome the needle phobia. :drinks

Suzanne, you should consider undertaking an LA course. It will greatly increase your job satisfaction and obviously your scope of practice. When I was at uni, we were only taught digital ring blocks, so I sought out a private practitioner (Steve Wells) who was willing to mentor me in tib blocks and we experimented with local infiltration techniques.

Cheers,
Bel

 

I will have to try and overcome my phobia and do the LA course. Anyone any ideas about verrucae until then? after all it will take a while for me to do that and the enquiries just keep on coming.

 

After reading threads here, I used the needling technique and it surely does work - thank you Kevin. My question is how does one bill for needling?
This is a wonderful site full of great mentors, very helpful for new practioners, thank you all!

 

Hi everyone
Thought I would add to this thread. I have been following it for a couple of months and have become really interested in the multiple puncture technique. I attended a conference not too long ago by Tim Kilmartin and Claire O'Kane and they presented a video of the technique. This combined with all the great photos and information on the arena inspired me to undertake my first treatment. Details below:

38 yr old female healthy pt presented with a verruca on her right 1st IPJ, plantar aspect. The patient informed me that the verruca has been present for approximately 4 yrs. She has never received any professional treatmet, but has tried 'every treatment available'; over the counter caustics and cryo treatments, banana skins, duct tape etc. After a consultation with the patient we both decided that multiple puncture technique was the probably the best option. In my experience this verruca was too long standing and probably was'nt going to disappear in a couple of repeat treatments with sal acid or silver nitrate. Photos below (pic 1. pre debridement, pic 2. post debridement, pic 3. post puncturing):

 

I'll update photos as I review the patient.

 

Hi all
thx for all the amazing photos better than a thousand words

just wondering whether anyone can point me to some resources about PT block, never did it before

 

Where are you??

 

Hello again all,

The following are pictures at the 8 week follow up for the patient I presented to the forum April 29th (pre and post debridement).

Sadly, my first attempt at needling didn't seem very successful. I made my best attempt to follow of Kevin's advice as closely as possible but all VPs persist and bled readily with debridement. There may be some improvement in terms of appearance but nothing like the results others have posted previously.

I'll be seeing him again at the 10 week mark.

I know others have mentioned the option of attempting to needle a second time - but does anyone think the results I've gotten so far would warrant it?

Thanks!

 

I have not done the "needling" but from what I understand the area heeds to be heavily pierced and bleeding. This photo doesn't look to me as I would have imagined it after the treatment.Also the area needs to be anaesthetised before needling.

 

Do you own a Biogun or have you just heard of it? When I started in practice I had a patient with a very persistent mosaic verruca and I bought the Biogun as the last resort. It worked. I have been using it successfully ever since. It stimulates the immune system by bombarding the area with charged particles, oxide ions. Air is not normally a conductor of electricity but under a large potential difference the oxygen in the air is ionised and becomes a carrier. If the keratolytic on its own is ineffectual but with the Biogun it works that is a synergistic effect.

 

Well, that's the theory anyway.

There is no actual evidence that the Biogun works that way, or even that it works (no clinical trials that I've been able to find).

Davidh

 

No, I don`t own one. I did have a play with one around 9 years ago. Can`t say I was impressed then and as my friend Mr Holland said, we`re still waiting for evidence of how the Biogun "distinguishes between virally-invaded cells and normal skin cells and is therefore effective against verrucae" (taken from the Dentron website).

Hmmmm. I`ve been familiarising myself with clinical immunology (specifically in relation to HPV) for a couple of months now and can`t say that I have come across anything which would suggest an air purifier would have such an effect. There are quite a few (cheaper) products out there which claim to `emit negative ions and promote overall wellbeing....` right, Ian?

Glad to hear you have success with the Biogun. I like a placebo as much as the next Barnum, but 2k is a lotta lolly for a device which is lacking scientific evidence of efficacy in treatment of VPs.

Just my view, of course.

Cheers,
Bel

 

It was 1k and paid in instalments over 10 months or so. I can't remember now.

I am not trying to convince you or anyone.

Cheers
Zsuzsanna

 

Steve

Ive just qualified and have been regularly turning away patients with VPs (whilst on placement in most PCTs in NHS) so am VERY keen to get some first-hand visual knowledge (I have done electrotherapy myself which I enjoyed but didnt get to see any LA infiltration at the time). I have done about 12 procedures (PNA/TNA) whilst studying but rarely got to grips with VPs.

I would VERY much appreciate shadowing you at a time of your choosing (although sounds like you may be quite full already!!!)

With kind regards

Linda

 

I know my math isn`t great, but;
http://www.dentron.co.uk/contents/en-uk/d24.html
Anyway, as I said, whatever works for you.

You wont go wrong with Steve. He and I spent a couple of afternoons practising LA techniques. Learnt a lot from him.

Cheers,
Bel

 

AKYC. As has been observed, nowhere near enough damage there. I needle until no resistance but a general rule of thumb I find is about 100 punctures for each 5mmsq of VP.

Linda, if you want any Tib block practice, I'm in Maidstone.

And to all, please PLEASE give yourselves proper names!! Between the AFYC, the dragons, the kalidoscopes etc it gets bloody hard to remember who's who!

 

Forget it. I`m not changing back again. "e"`s are overated.